NCM31112L Activity 2

Case 1

Maria, 35 was admitted to the hospital for shortness of breath, weakness, productive cough, chest pains and epigastric
discomfort. Vital signs upon admission were: T- 38 degrees centigrade, PR- 105 beats/min, irregular and weak, RR- 30
cpm, BP-100/60 mmHg. She has been experiencing discomfort for 1 week prior to admission. She was given orders for
bed rest and a low salt, low fat diet. Upon assessment, the nurse found out significant findings such as pale nail beds,
conjunctiva, rales on both lower lung fields, and reduced lung excursion and increased fremitus. Skin was flushed and
warm with dryness; no lesion noted. Maria reported poor appetite for 1 month and had vomiting episodes every now
and then following abdominal pains 2-3 hrs after meals and at night. She drinks 1 glass of water every meal to avoid
going to the bathroom frequently. Her stools appear soft and dark brown in color; no pain upon defecation noted. She
lacks sleep and appears haggard owing to her discomfort and cough. She is still able to do ADLs but reports fatigue and
weakness often in the day.

When asked about her health history and practices, she reported having frequent sore throat which she thinks comes
from excessive intake of salty and hot food. She has heredo- familial disease such as hypertension and CAD. When she
feels sick, she manages her discomforts with herbal supplements sold to her by her officemates in the office.

Her present hospitalization is affecting her role as a breadwinner for her family. She verbalizes “What is going to happen
to us now that I am in the hospital? I feel so bad not being healthy but I know God has a purpose for everything.” Her
husband often visits her in the hospital after attending to their two kids in elementary school.

Laboratory exams for Maria revealed the following:

Chest X-ray
Lung consolidation, bilateral lung fields. Heart appears normal

CBC
WBC- 18,000/mm³
RBC- 3x10⁶Ul
Hgb-8.5g/dl
Hct- 40%
WBC Differential
Neutrophils- 52 %
Lymphocytes- 42%
Monocytes- 2%
Eosinophils- 2%
Basophils- 1%
Platelet count 200,000/mm³

Lipid profile
Total cholesterol- 300 mg/dl
HDL- 40 mg/dl
LDL- 250 mg/dl
Triglycerides 180 mg/dl

EGD and Colonoscopy

Bleeding ulcer noted below the pyloric junction measuring 3x4 cm. superficial gastric irritations on mucosa noted.

Urinalysis
Appearance- clear Glucose- negative
Color- dark yellow Cast- none
pH- 5.0 WBC- 1-2
Protein- negative RBC- 0-1
Sp. Gravity- 1.005

Brgy. Paciano Rizal, Calamba City, Laguna, 4027 Philippines  Tel. No.: (049) 834-1159
www.perpetualdalta.edu.ph
Calamba Campus
Fecalysis
Color- dark brown
Consistency- soft – formed
Occult blood- positive
Pus- negative
Ova and parasites- none seen

Upon reading the patient’s chart, the medication ordered for the patient are the following:
1. Paracetamol 500mg tab every 6 hrs PRN for fever
2. Iron supplement 1 cap once a day
3. Esomeprazole 40 mg once a day
4. Amoxicillin 1 gm 2x a day
5. Clarithromycin- 500mg 2x a day
6. Irbesartan 300mg once a day

1. What will be your focused physical assessment priorities before you start your care for Maria (10 pts)
2. Interpret the diagnostic lab results for the case. Correlate the significant diagnostic test and Physical assessment
findings with the pathophysiology of the condition (20 pts)
3. Assuming Maria was transfused with 1 bag of PRBC, what is the role of this intervention and your nursing
responsibilities for its administration? What position and diet modifications will be advised for her to help
manage her symptoms? (20 pts)
4. Formulate a comprehensive Nursing Care Plan for this case using the format below (50 pts)

Cues/ Evidences Nursing Diagnosis Objectives Nursing Interventions Rationale

To be submitted on or before September 28, 2020 (Monday)

Email output to:

angelica.eugenio@perpetual.edu.ph
ajeugenio227@yahoo.com

Thank you very much and God speed

In Mother of Perpetual Help

MARIA ANGELICA M. EUGENIO, RN, MAN, Ed.D

Program Chair, College of Nursing

Brgy. Paciano Rizal, Calamba City, Laguna, 4027 Philippines  Tel. No.: (049) 834-1159
www.perpetualdalta.edu.ph
Calamba Campus